Scand..J. Dent. Res.

1978: 86: 366-373

(Kcv words: pulp diseases: pulpedomy: root canal therapy)

Clinical and radiographic study of pulpectomy

and root canal therapy
M. A. JOKINEN, RISTO KOTILAINEN, PEKKA POIKKEUS, RAIJA POIKKEUS
AND LEENA SARKKI

Institute of Dentistry, University of Helsinki, Helsinki, Finland

ABSTRACT - A clinical and radiogi-aphic reexamination of 2,459 roots 2—7 years after initial
pulpectomy or root canal therapy is presented. The overall success rate, which was 53%, was
not affected by the sex or age of the patient, or by the jaw in which the tooth was situated.
Tlie tooth group, however, had a significant influence on the success rate, the worst results
being obtained for incisors and especially the mandibular central and maxillary lateral
incisors. The prognosis was clearly better for the pulpectomies than for the root canal
therapy. Mortal pulpectomy was found to succeed more often than vital. The presence of a
primary periapical rarefaction worsened the success rate. The success rate was lower for the
teeth in which a posttreatment prosthetic crown had been fitted. Fillings which went
beyond the apex had a significantly lower success rate than those which nearly or exactly
readied the apex.

(Accepted for publication 21 May 1978)

The criteria for recognition of successful
pulpectomy and root canal therapy are ill-
defined. The evaluation is usually based
on a periapical radiograph and the
clinical signs and symptoms, though
histologic or bacteriologic studies have
been reported, albeit rarely. The
combined reports of histologic and
radiographic findings, however, have
shown a good correlation between these
two methods of evaluating periapical
disease (ENGEL 1950, WENGRAF 1965,
BRYNOLF 1967).
The interpretation of the radiographs
has varied between studies. Thus a normal
periapical region at a defined time after
therapy has been the criterion of success
in some studies while partial healing of a
prior rarefaction was sufficient in others.
Further, the "complete healing" in some
reports tolerates a radiolucent area
around excess filling (STRINDBERG 1956,
GRAHNEN & HANSSON 1961).
If the criterion of success is complete
osseous regeneration, success rates fall to
39-6296 (BENDER, SELTZER & SOLTANOFF
1966).
The postoperative observation time has
also varied in different investigations from
6 months to 18 years. NICHOLLS (1961), in
a review of the literature, concluded that,
as a general rule, a 2-year period may be
considered adequate. SELTZER, BENDER,
SMITH, FREEDMAN & NAZIMOV(1967) also
pointed out that though failure might be
observed even 10 years after operation,
the vast majority of unsuccessful cases
were noticed within 2 years of treatment.
 PULPECTOMY AND ROOT CANAL THERAPY
STRINDBERG (1956), on the other hand,
claimed that a 4-year observation period
was needed.
The age and sex of the patient are not
usually considered to affect the success
rate, while the initial periapical rarefac-
tion and overfilling are generally thought
to reduce the percentage of successes
(HOLST 1941, CASTAGNOLA 1950,
STRINDBERG 1956, GRAHNEN & HANSSON
1961, SELTZER et al. 1967). Several
investigations have shown that the tooth
group affects the success rate, with the
worst results for incisors (GoOD 1943,
FECHTER 1955, STRINDBERG 1956,
GRAHNEN ^ HANSSON 1961, ENGSTROM &
LUNDBERG 1965, BERGENHOLTZ,
MALMCRONA 8C MILTHON 1973).
Material and methods
This study includes all patients subjected to
pulpectomy and root canal therapy at the
Department of Endodontics, Institute of
Dentistry, University of Helsinki, in the years
1964-69. Eor each patient the following data
were recorded: age and sex, diagnosis of the
treated tooth, medication, type of treatment,
periapical condition and the subsequent
restorative treatment. The treatments were
carried out by students under the supervision
oi teachers.
When the pulp was vital, it was extirpated
under local anesthesia or after devitalization
with a paraformaldehyde paste. The root
canals were cleansed mechanically with
reamers and files, and Decal*, an organic acid,
was used to irrigate the root canal.
Teeth with necrotic or gangrenous pulp were
root filled after mechanical and chemical
irrigation (hydrogen peroxide 5% and Decal).
The canals were medicated with a
chemotherapeutic corticosteroid preparation
Triodent* (dexamethasone sodium phosphate,
dequalone acetate, 5+10 mg/ml), except in 317
cases which were treated with the same prep-
aration without the corticosteroid. When acute
367
periapical osteitis was diagnosed, systemic
antibiotic therapy, usually penicillin, was used.
The canals were filled with chloropercha
condensed with guttapercha points. Rubber
dam protection was used when there was
enough crown present. In about half of the
cases, however, the treated tooth was isolated
from saliva with cotton rolls. No bacteriologic
tests were carried out on the root canal
content.
A preoperative radiograph was always taken
and, if necessary, a second radiograph was
taken with a reamer inserted into the root
canal in order to calculate its length. A
postoperative radiograph was taken in order to
assess the quality of the filling. Only dense
fillings were accepted.
Patients were recalled for examination in the
period 1968—76. The clinical evaluation
included the following: subjective symptoms,
sensitivity to percussion, evidence ^of fistula,
presence of swelling. A stereoradiograph was
taken in all cases and reported separately by
two investigators (M.A.J. and R.K.). When
opinions differed, the cases were reexamined
together.
The whole material treated during the
period 1964-69 and the reexamined material
finally used in the analysis are shown in Table
1. Throughout, rates are given per root. The
reasons for exclusion are shown in Table 2.
These cases have not been interpreted as un-
conditionally unsuccessful because in none of
them could it be proved that the reason for ex-
traction had been the failure of the endodontic
treatment.
In this investigation overfilling and un-
derfilling means fillings that go more than
0.5 mm beyond or end more than 0.5 mm
before the radiographic apex of the root.
The criteria for success were: (1) a
radiographically healthy periapical bone
structure, periodontal membrane and con-
tinuous lamina dura and (2) absence of
symptoms. Cases in which the area of an initial
rarefaction had definitely become smaller, but
in which bone repair was incomplete, were
classified as "doubtful".
An unsuccessful case was one in which an
area of rarefaction had developed where none
was present initially, or in which an initial area
of rarefaction had persisted or become larger,
or in which the tooth showed symptoms.
In statistical analyses the chi-square method
was used.
368 JOKINEN ET AL.

Table 1
Material ofthe investigation

Excluded for
Entire material Did not respond various reasons Final
to several recalls (Table 2) material
n % n % n 96

Patients 2,592 1,272 49 121 4.7 1,199 45.8

Teeth 261 1,782
Roots 2,459

Table 2
Reasons for the exclusion of 261 teeth

Unsatisfactory radiographs 93
Extraction of teeth for prosthetic reasons 55
Extraction of teeth because of detached filling,
new carious lesions or acute symptoms in the area 40
Extraction of tooth for unknown reasons 73

Total 261

Results different teeth. The success rate was much

The results obtained in the clinical and
radiographic reexamination of the
pulpectomies and root canal therapy are
presented in Tables 3-6.
Where a certain group contained a
significantly high proportion of incisors,
overfilled roots or cases with initial
rarefaction, all of which have been found
to afFect the results adversely, a
supplementary analysis was made by
excluding such cases from that group.
O^ the total material 1,304 procedures
(53 96) were successful, 314 (13%) doubtful
and 841 (34%) failures.
Jaw — The success ratios for the
mandible and the maxilla were very
similar (F>0.03, Table 3).
Tooth group — There were marked
differences between the success rates for
the different tooth groups and for
lower for the incisors than for the other
groups of teeth, and was especially low for
the mandibular first and maxillary second
incisors (Table 3).
Sex and age - The sex and age of the
patient had only a small effect upon the
success rate (Table 4) (P> 0.05).
Observation time - In root canal therapy
the success rate was low during the first 3
years after treatment. Subsequently the
rate was steady except for the 7-year
observation period, when the results were
better than average. In the pulpectomy
series the success rate was consistently
above 60% except for the period 4 years
after therapy (Table 6).
Diagnosis and type of treatment - The
prognosis was better if the pulp had been
vital before treatment and mortal pulpec-
tomy was found to succeed more often
than vital (Table 4).
 PULPECTOMY AND ROOT CANAL THERAPY 369

Table 3
Results ofpulpectomies and root canal therapy in different jaws and tooth groups

Successful Doubtful Failures Total

Mandible 595 55 127 12 355 33 1,077 44

First incisors 11 22 7 14 32 64 50 2
Second incisors 18 35 7 14 26 51 51 2
Canines 45 48 13 14 35 38 93 4
First premolars 47 57 9 11 27 32 83 3
Second premolars 91 62 16 11 40 27 147 6
First molars 198 53 43 11 136 36 377 15
Second molars 162 66 28 11 57 23 247 10
Third molars 23 79 4 14 2 7 29 1

Maxilla 709 51 187 14 486 35 1,382 56

First incisors 81 40 37 18 84 42 202 8
Second incisors 49 26 38 20 104 54 191 8
Canines 74 49 22 15 54 36 150 6
First premolars 78 44 35 20 64 36 177 7
Second premolars 93 64 8 6 44 30 145 6
First molars 233 64 35 10 95 26 363 15
Second molars 101 66 12 8 41 26 154 6

Table 4
Results of pulpectomies and root canal therapy grouped according to sex, age, diagnosis or treatment method
and the presence of an initial rarefaction

Successful Doubtful Failures Total

n % n % n % n %

Female 825 53 215 14 523 33 1,563 64

Male 479 54 99 11 318 35 896 36

16-29 years 605 52 147 13 407 35 1,159 47

30-49 years 480 54 107 12 298 34 885 36
50—75 years 219 53 60 14 136 33 415 17

Vital extirpation
CTl

441 54 76 296 37 813 33

Mortal extirpation 270 66 31 8 107 26 408 17
Necrosis pulpae 227 67 36 11 74 22 337 14
Chronic osteitis 135 36 73 20 165 44 373 15
Acute osteitis 231 44 98 18 199 38 528 21

Without initial
rarefaction 984 61 146 9 488 30 1,618 66
With rarefaction 320 38 168 20 353 42 34
370 JOKINEN ET AL.

Table 5
Results of pulpectomies and root canal therapy grouped according to medication, preparation of a prosthetic
crown after the treatment and the type of filling

Successful Doubtful Failures Total

Corticosteroid
medication 1,159 54 276 13 707 33 2,142 87
Witiioui
corticosteroid 145 46 38 12 134 42 317 13

Prosthetic crown 345 46 106 14 297 40 748 30

Without prosthetic
crown 959 56 208 12 544 32 1,711 70

Uiulcrfilled 461 70 40 6 159 24 660 27

Filled to the apex 338 57 63 11 187 32 588 24
Ovcrlillcd 505 42 211 17 495 41 1,21! 49

Table 6
Resulls of pulpectorniei and root canal therapy according to the length of the period of
observation

Duration of
ol)seryation Successful Doubtful Failures Total
period
n 96 n 96 n % n

Pulpeclomies
2-3 vcars 10 66 1 7 4 27 15
4 yea IS 126 46 21 8 128 46 275
5 vcars 172 60 23 8 91 32 286
6 N'cars 291 62 49 10 132 28 472
7 vcars 112 65 13 7 48 28 173

Total 711 58 107 9 403 33 1,221

Root canal therapy

2—3 years 6 25 8 S3 10 42 24
4 years 90 48 26 14 71 38 187
5 years 124 45 42 15 108 40 274
5 years 279 47 111 18 208 35 598
7 vears 94 61 20 13 41 26 155

Total 593 48 207 17 438 35 1,238

 PULPECTOMY AND ROOT CANAL THERAPY 371

When all incisors and overfilled roots the success rates were: filled short of the
were excluded from the material, the apex, 7296; filled to the apex, 6296; over-
success rate for vital extirpation was 6496 filled, 47 96. When the cases with initial
and for mortal extirpation 7596. Both rarefaction were also excluded, the
chronic and acute osteitis cases had a respective success rates were 7596, 6596
success rate of 5896. When grouped by and 5596. These differences were
diagnosis and type of treatment there were statistically significant (P<0.001).
statistically significant differences
{PKO.OOD.
Initial periapical rarefaction — The Discussion
presence of a primary periapical rarefac-
tion lowered the success rate significantly The general success rate for pulpectomies
(/'< 0.001, Table 4). When all incisors and root canal therapy in the present in-
were excluded, the success rate for cases vestigation was similar to those in pre-
without initial rarefaction was 6596 and viously reported studies when the same
with rarefaction 4396. When all overfilled stringent criteria for success were applied.
roots were excluded, the success rates It is possible, however, that use of
were 7196 and 5596 respectively. These bacteriologial methods would have
differences were statistically significant produced improved results, as suggested
by ENGSTROM & LuNDBERG (1965). On the
Type of medication - Roots treated with a other hand, SELTZER et al. (1967) have
medicament that contained corticosteroid stated that the prefilling bacteriologic tests
had a better success rate than those did not significantly affect the success rate
treated without corticosteroid (P<0.01, for endodontic treatment.
Table 5). Sex and age - The sex and age of the
Crown prosthetics - The teeth that were patient did not significantly affect the
fitted with a prosthetic crown after the success rate for pulpectomies and root
treatment had a significantly lower success canal treatment and this is in agreement
rate than those without a prosthetic crown with the results of most previous in-
(P< 0.001, Table 5). This tendency vestigations (HOLST 1941, CASTAGNOLA
towards poorer results in the prosthetic 1950, STRINDBERG 1956, GRAHN£N &
crown group persisted when all the HANSSON 1961, SELTZER gi a/. 1967).
incisors had been excluded, the success faw - SELTZER et al. (1967) found that
rates being 5496 and 6096 for crowned and failure of pulpectomies and root canal
uncrowned teeth respectively. This treatments occurred more frequently in
difference was statistically significant at maxillary than in mandibular teeth. In the
the 296 level (P<0.02). present study there were no such signifi-
Type of filling — Overfilled roots had a cant differences in results between
much poorer success rate than roots maxillary and mandibular teeth, which is
which had been filled to or short of the in accordance with the investigation of
apex (/^< 0.001, Table 5). The difference GRAHNEN&: HANSSON (1961).
was more marked in the root canal Tooth group - The present study confirms
therapy group, the success rate being 7296 the finding that the tooth group has a
when underfilled, 5696 when filled to the significant influence on the success rate.
apex and 37 96 when overfilled. When the The rate was best in the molar and worst
incisors were excluded from the material, in the incisor groups. Though the
25
372 JOKINEN

mandibular central incisors in particular factual. In his investigation, however,

had a high (70%) percentage of deeper probing was carefully avoided.
overfillings, which may partly explain the As demonstrated in most previous in-
poor success rate, the low success rate for vestigations, the presence of a primary
the maxillary second incisors may be periapical rarefaction worsens the
more attributable to the frequency of prognosis for root canal therapy. This is
radicular cysts found in this tooth group understandable as the healing process is
(MORTENSEN, W1NTHER& BiRN 1970). For slower when the inflammatory reaction
the mandibular lateral incisors, the high has spread outside the root canal.
percentage (77% according to LAV^S 1971) Type of medication - The roots treated
of bifid canals probably is not the reason with a medicament containing cor-
for the poor success rate, because the ticosteroid had a better success rate than
frequency of bifid canals with double those treated without corticosteroid.
loramina is quite low (3% according to However, as the mean length of the
LAWS 1971). The present authors could observation time was significantly greater
not find any well-founded explanation for in the corticosteroid group, longer term,
the poor success rate for the mandibular studies are in progress and will form the
lateral incisors. STRINDBERG (1956), basis of a later report.
however, suggested that the reason for the Prosthetic crowns - In the teeth fitted with
higher failure rate of single-rooted teeth a prosthetic crown there was a
could lie either in the greater mobility of significantly lower success rate compared
their roots or in their nutritional con- with those without such a crown. This
ditions, which are worse than for multi- may be explained by the fact that a major
rooted teeth. proportion of the crowning procedures
Observation time — The success rate was were for incisors, which have been shown
found to be low in the first 3 years after to have a lower success rate than other
root canal therapy, which indicates that groups of teeth. After having excluded the
the healing process is a slow one. The fall incisors from the material, however, the
in the success rate for pulpectomies after 4 success rate was still slightly lower. This
years might have been due to a chronic could be explained by the possible
irritation reaction from the necrotic pulp damage caused to the root-filling during
remnants, which eventually disappeared the crown preparation, and by the
owing to the resorptive activity of the possibility of traumatic occlusion causing
periapical tissues. pressure to the periodontal tissues, thus
Type of treatment - The fact that the preventing healing (SELTZER et al. 1967).
success rate was found to be better after Type of filling — The results of this study
mortal than after vital pulpectomy is accord with those of most previous in-
contrary to general opinion. A possible vestigations in cases of overfilling,
explanation is that instrumentation showing that it significantly reduces the
beyond the apex is by far more frequent success rate (GASTAGNOLA 1950,
when local anesthesia is used. LAMBJERG- STRINDBERG 1956, GRAHN£N & HANSSON
HANSEN (1974), however, could not 1961, SELTZER et al. 1967, BERGENHOLTZ
demonstrate differences in tissue et al. 1973). Foreign materials may have an
reactions, and concluded that the irritating effect on the periapical tissues,
difference between vital and mortal and overfilling is often preceded by
pulpectomy was more theoretical than probing of the periapical region, which
 PULPECTOMY AND ROOT CANAL THERAPY 373

may push pulp remnants and GOOD, J.: Resultate der Pulpaexstirpation und
microorganisms beyond the apex. Gangrdnbehandlung nach der Walkhoffschen
Methode nach rontgenologisch statistischen
Nachkontrollen. Thesis. Zurich 1943.
GRAHNEN, H . & HANSSON, L . : The prognosis
of pulp and root canal therapy. Odontol.
Revy 1961: 12: 146-164.
References HoLST, J. J.: Resultater af rodbehandling paa
grundlag af en klinisk-rontgenologisk
BENDER, 1. B., SELTZER, S. & SOLTANOFF, W . : efterundersogelse af 418 tilfaelde.
Endodontic success-A reappraisal of Tandlaegebladet 1941: 45: 330-348
criteria. I-Il. Oral Surg. 1966: 22; 780-802. LAMBJERG-HANSEN, H . : Vital and mortal pulp-
BERGENHOLTZ, G., MALMCRONA, E. & ectomy on permanent human teeth. Thesis. Scand.
MtLTHON, R.: Endodontisk behandling och J. Dent. Res. 1974: 82: 243-332.
periapikalstatus. II. Rontgenologisk LAWS, A. J.: Prevalence of canal irregularities
bedomning av rotfyllningens kvalitet stalld i in mandibular incisors. A radiographic
relation till forekomst av periapikala study. N. Z. Dent.J. 1971: 67: 181-186.
destruktioner. Tandlaekartidningen 1973: 65: MORTENSEN, H., WiNTHER, J. E. & BiRN, H. :
269-279. Periapical granulomas and cysts. An in-
BRYNOLF, L : A histolo^cal and roentgenological vestigation of 1600 cases. Scand. J. Dent. Res.
study of the periapical region of human upper 1970: 78:241-250.
incisors. Thesis. Odontol. Revy 1967: 18: NiCHOLLS, E.: An investigation into the factors
Suppl. 11: 1-176. which may influence the prognosis of root canal
CASTAGNOLA, L . : 1000 Ealle von Gangran- therapy. Thesis, University of London 1961.
behandlung nach der Walkhoffschen SELTZER, S., BENDER, I. B., SMITH, J.,
Methode aus dem statistischen Material der FREEDMAN, 1. & NAZIMOV, H . : Endodontic
konservierenden Abteilung. Schweiz. failures—An analysis based on clinical,
Monatsschr. Zahnheilkd. 1950: 60: 1033-1072. roentigenographic and histologic findings.
ENGEL, H.: Die Behandlung infizierter I-II. Oral Surg. 1967: 23: 500-530.
Wurzelkanale und Granulome nach der STRINDBERG, L. Z : The dependence of the
Methode von Walkhoff. Schweiz. Monatsschr. results of pulp therapy on certain factors.
Zahnheilkd. 1950:60: 1077-1109. Acta Odontol. Scand. 1956: 14: Suppl. 21:
ENGSTROM, B. & LuNDBERG, M.: The 1-175.
correlation between positive culture and the WENGRAF, A. M . : Angulation in periapical
prognosis of root canal therapy after radiography. Br. Dent. J. 1965: 118:
pulpectomy. Odontol. Revy 1965: 16: 528-531.
193-203.
FEGHTER, B.: Ergebnisse von mehreren Address:
Tausend in der freien Praxis nach M. A.Jokinen
wissenschaftlich anerkannten Methoden Lepolantie 37H
durchgefuhrten Wurzelbehandlungen. SF 00660 Helsinki 66
Dtsch. Zahnaerztl. Z. 1955: 10: 1677-1684. Finland